LA RECUPERACIÓN DESPUÉS DEL TRAUMA

Beyond recovery from trauma: implications for clinical practice and research - Thriving: Broadening the Paradigm Beyond Illness to Health http://findarticles.com/p/articles/mi_m0341/is_2_54/ai_53489955/print

The lifetime prevalence of major stressful events is high. In one study of

1,000

adults in four cities in the southeastern United States, for example, 21% of the sample reported a traumatic event (such as a robbery, assault, or traumatic death of a loved one) during the previous year and 69% reported the occurrence of at least one such event in their lifetimes (Norris, 1992). Although the frequencies of reported events vary across studies, "it is clear that exposure to 'traumatic' events is common in the lifetime of individuals, at least in the United States" (Green, 1994, p. 344).

As has been made clear throughout this issue, perceiving and experiencing psychological growth, or thriving, as a result of the struggle with highly stressful events has been recognized clinically for some time (Caplan, 1964). More recent systematic investigations have confirmed the clinical impressions. The phenomenon of perceiving positive self-change originating in the struggle with trauma has been found to occur in a significant proportion of persons as a result of a wide range of disruptive events (O'Leary & Ickovics, 1995; Tedeschi & Calhoun, 1995).

The major focus of this article is on implications of the work on thriving and posttraumatic growth for the working clinician and on areas in need of additional investigation.(1) This article draws implications in four areas: the relation of psychological well-being and thriving, a conceptual framework for the practicing clinician, a discussion of the encouragement of thriving in clients, and suggestions for further research.

However, not all investigations of the links between growth and adjustment find a reliable connection (Joseph, Williams, & Yule, 1993). For example, an investigation of persons whose spouse or child had died in a motor vehicle accident (Lehman et al., 1993) failed to find a significant relationship between number of positive changes reported and psychological adjustment. A similar pattern of results was obtained in a study of persons suffering from rheumatoid arthritis (Tennen, Affleck, Urrows, Higgins, & Mendola, 1992). In that study, perceiving benefits in the struggle with the pain of arthritis was not related to measures of daily mood.

As these examples illustrate, the data on the relationship of measures of growth or perceived benefit after trauma and measures of psychological adjustment are limited and somewhat inconsistent. An increased experience of growth may be related to increased adjustment in some instances (Curbow, Somerfield, Baker, Wingard, & Legro, 1993), but not in others. However, there is no indication that perceiving benefits in one's straggle predicts negative psychological functioning (Tedeschi & Calhoun, 1995). At the current stage of research, there is no clear explanation for the inconsistency of findings. Perhaps the simplest explanation for these inconsistent results is that sometimes growth and adjustment are not predictably related. Another possibility is that growth at one specific point in time may be related to adjustment, but only to adjustment at another, different point in time, for example, at some point subsequent to a time of most growth. The clinician must also bear in mind that well-being and distress are not necessarily opposite ends of the same pole. Positive and negative affect can be independent dimensions (Bradburn, 1969). The available data also suggest that growth may be differentially related to positive affect, on the one hand, and negative affect, on the other (Goodhart, 1985).

Posttraumatic growth is set in motion by the same sets of events that produce psychological distress and that can also place the individual at increased risk for psychological difficulties. The individual experiences what constitutes an event of "seismic" proportions (Calhoun, 1996; Calhoun & Tedeschi, 1998). The circumstances which the individual has had to face must have been capable of at least shaking the foundations of the individual's assumptive world, and in some instances some shattering of fundamental assumptions may occur (Janoff-Bulman, 1992). The traumatic set of circumstances typically causes high degrees of psychological discomfort and a major invalidation, or at least major disruption, of important cognitive elements. The trauma typically leads to a questioning and reevaluation of many important assumptions previously held. And it is in the reevaluation, modification, or rebuilding of one's general assumptions about, and views of, the world that posttraumatic growth may be most readily addressed in the clinical setting. Precisely because of the violation of fundamental assumptions that have provided structure and meaning to life, we see both distress and growth coexisting in persons in the aftermath of trauma. Persons who have struggled with the death of a loved one provide a good example. Such persons' grief is typically characterized by sadness, anxiety, somatic complaints, considerable loneliness, and varying degrees of yearning for the person who has died (Weiss & Richards, 1997). Although for many persons the pain diminishes with time, this is not the case with everyone (Wortman & Silver, 1989). Persons who must face bereavement may also experience significant psychological growth (Calhoun &

Tedeschi, 1989-90; Yalom & Lieberman, 1991), but the psychological pain associated with the loss may persist.

Yalom & Lieberman (1991) tell about the impact on a 55-year-old woman of her husband's death. In the struggle with her loss she had experienced and had made a variety of positive changes in her life. She stopped smoking, she began to exercise, she became very much aware of how precious life is, she had experienced a significant change in life priorities, and she began to search for a way to make a difference in the world. At the same time, however, she was frightened by her life's lack of structure, she had strong regrets about how she previously had chosen to live her life, and she had become acutely aware of her own mortality. This woman offers a good example of what clinicians may see in their clients who seek help in dealing with highly stressful events: a mixture of positive changes that typically do not occur in all possible domains of posttraumatic growth, and at the same time, a series of negative experiences that persist in the wake of the difficult circumstances.

Elements of Treatment Individuals who seek treatment because of difficulties precipitated by traumatic events typically have high level of distress and have not yet found the crisis to be manageable. In working with such persons several different elements need to be present in treatment (Herman, 1992; Van Der Kolk, McFarlane, & Weisaeth, 1996).

In the earlier phases of treatment, the individual's general psychological state must be stabilized. For this to happen, the individual needs to feel safe and to experience the therapeutic relationship as a secure one. The focus on safety, both physical and psychological, is particularly necessary where the crisis exposes the client to the potential of significant harm, for example, sexual assault, childhood physical abuse, or the presence of a threatening and abusive marital relationship.

Additional elements of intervention may need to focus on dealing with the symptoms of intrusion (unwanted images, nightmares, intrusive ruminations about the event) and various forms of conditioned avoidance (fear and avoidance of situations similar to that in which the event occurred), the reestablishment or renewal of meaningful connections to the individual's support system, and the rebuilding and restructuring of the assumptive world. It is in this latter clinical domain that the implications of posttraumatic growth for psychological intervention are most relevant.

The Struggle Toward Wisdom We have described elsewhere the relationship between recent conceptualizations of wisdom and posttraumatic growth (Calhoun & Tedeschi, 1998; Tedeschi & Calhoun, 1995). One reason traumatic events may be "wisdom-facilitative" (Baltes, Staudinger, Maercker, & Smith, 1995) is because there is such a strong element of affect in the experience of trauma, and wisdom appears to have a strong affective component as well. It is not merely intellectual understanding. The demolition of old cognitive structures that provided a map for life and the struggle to rebuild are experienced, not merely observed.

Survival in the midst of this chaos appears to involve the experience of paradox that is such an important element of wisdom. The discovery of creative coping approaches that embrace paradox lead to the recognition and management of uncertainty. For example, to manage trauma one must be active, yet let time take its course; one must accept help, yet recognize that ultimately no one else can manage the trauma; and one must acknowledge that the trauma must be left in the past but also woven into the future. Discovering and experiencing this in the posttrauma struggle involves the joining of the intellectual and affective in a powerful new recognition of what it means to survive, then thrive.

Growing by Explaining This woman was still experiencing high levels of distress, months after her husband's death, but she was also reporting and experiencing elements of thriving - she had changed in ways that she regarded as highly positive, in spite of her continued pain over the loss of her husband. She had experienced significant cognitive change, both positive and negative. Although she saw herself as a stronger, more capable person, she also had a greater degree of concern for her own safety and found herself worrying excessively about the safety of loved ones when they traveled. Her understanding of who she was, of the world and her place in it, of her role in life, and of her connections to other persons were radically changed. Although many of the changes she had experienced were negative and continued to be so, there clearly were many elements of what others might describe as "existential wisdom" (Yalom & Lieberman, 1991), in particular, or wisdom more generally.

A clear element in Ashlee F.'s increase in wisdom was a greater appreciation for spiritual and religious elements in her life. But at the same time she was aware that for her, simplistic religious explanations that had been comforting for her in the past were no longer useful. Ms. F's experience reflects an important component in

posttraumatic growth, at least in a significant portion of the persons who have participated in our research (Calhoun, Tedeschi, & Lincourt, 1992; Overcash, Calhoun, Cann, & Tedeschi, 1996; Tedeschi & Calhoun, 1995, 1996) and with whom we have done clinical work: an increased sense of the importance of existential, spiritual, or religious aspects of their lives. Posttraumatic growth manifested in increased wisdom is also broader than that in the existential domain.

We next consider some general guidelines for the clinician to follow during this process of narrative development that leads to perspectives on life that have elements of wisdom.

Encouraging Growth The available data on posttraumatic growth indicate clearly that for many individuals positive changes are identified in this existential or spiritual domain (Tedeschi & Calhoun, 1995). To encourage growth in these persons effectively, the clinician not only must feel comfortable dealing with these matters, but also must be capable of actively engaging the person who perceives growth occurring in this arena. Furthermore, the clinician must have the flexibility to tolerate the questioning, doubt, and change in the spiritual and religious realm as the survivor of trauma moves beyond an old belief system to a revised one. The clinician may be working within an evolving belief system and may not have any sense of what the final version may be. The therapist must be willing to act as a "midwife" in this process (Vaughan, Wittine, & Walsh, 1996). This role suggests a supportive expert who respects the survivor's ability to manage the difficult process naturally.

The clinician must be prepared for and willing to support the client's perceptions of thriving. Whether the client discovers or constructs (Neimeyer & Stewart, 1996) positive change, the clinician needs to support the perception of growth when it occurs. Although the issue of positive illusions is a matter that produces academic debate (Colvin & Block, 1994), positive illusions (Taylor & Brown, 1988) can be useful for clients in the process of posttraumatic growth. In some contexts the clinician may need to support a client's perception of growth that may objectively constitute an illusion. From a clinical perspective, it seems desirable to support a client's perception that he or she is now a different and better person, even if the individual has not measurably altered observable behavior. Such behavioral changes may come later, and the clinician can engage the survivor in discussions of how the changes may be shared. In many of the cases we have seen in clinical practice, people who are thriving may have a great motivation to share their hardwon gift with others who unfortunately have been forced by loss to join their community of suffering.

The key issue here is one of the proper timing of the proper intervention. What seems clear for the domain of posttraumatic growth is that for most persons, the clinician should not be looking for nor leading the client to focus on possibilities of growth in the immediate aftermath of a traumatic event. As the individual's coping mechanisms restore some degree of psychological equilibrium and reduce some of the most extreme distress, then the clinician needs to be alert to the possibility of helping the client identify areas of growth. We typically wait until clients make mention of changes themselves, and at first offer only gentle reflections of perceptions first articulated by the survivor.

A semantically minor but clinically important issue is how the clinician chooses to talk about and to help the client articulate the traumatic antecedents, or in the view of many clients, the cause of the individual's experienced growth. We have found, both in the context of clinical work and when we discuss our research work on growth with audiences of laypersons, that it is important to use words that clearly locate the impetus for growth in the arena of struggle with the event, not the event itself. For example, Harold Kushner, who described several elements of growth resulting from his own struggle with loss, was very clear in indicating that there was nothing inherently good in his son's death, and that he would gladly give up this growth in return for his son (Viorst, 1986).

Research With Clinical Implications Given the relative infancy of the systematic investigation of thriving, it is not surprising that there are plentiful questions that research can address, most with important clinical implications. One involves the degree to which the reported psychological experience of posttraumatic growth is accompanied by observable changes in overt behaviors. The recent development of inventories to measure growth (Park et al., 1996; Tedeschi & Calhoun, 1996) has made the reliable assessment of self-reported growth possible. But the research available so far has relied almost exclusively on such self-report data (Tedeschi et al., 1998). A necessary next research step is the evaluation of the degree to which self-reported posttraumatic growth tends to be accompanied, or not, by observable changes in behavior. This step would seem particularly needed in the domains of selfdescribed growth that have clear external referents. These would include, for example, increases in compassion and altruism, improved relationships with significant others, and greater skills in solving life problems.

A second question for investigation is: What implications does the experience of posttraumatic growth have for the long-term psychological adjustment of individuals exposed to highly stressful events? The available evidence is

characterized by inconsistent findings (Park, 1998) and by an absence of longitudinal data. Longitudinal investigations are needed that examine the relationship of posttraumatic growth to well-being and distress in the context of other variables relevant to adjustment to life crises. A variable of particular promise is ruminative cognitive processing.

The available data clearly indicate that the content and style of cognitive processing have high relevance for adaptation to highly stressful events (Greenberg, 1995; Nolen-Hoeksema, McBride, & Larson, 1997). Self-focused negative thinking has undesirable consequences for adjustment. However, posttraumatic growth tends to reflect cognitive changes that the individual views as positive, for example, an increased perception of self-reliance. In the same fashion that self-focused negative rumination predicts poorer future adjustment (NolenHoeksema et al.), it would seem reasonable to expect that self-focused positive rumination, that is, the cognitive experience of posttraumatic psychological thriving and growth, would predict better subsequent psychological adjustment. Although such investigations have been suggested (Calhoun & Tedeschi, 1998), they have not yet been undertaken.

A final area for continued investigation of growth is the domain of gender differences. There is evidence that men and women may use somewhat different approaches for coping with traumatic events, and that, on average, women are more likely to experience posttraumatic growth than men (Tedeschi & Calhoun, 1996). But the evidence is still somewhat contradictory and limited. As yet, little is known about the possible differences between men and women in the style, process, and content of posttraumatic growth. As Tennen and Affleck (1998) have recently suggested, "we encourage investigators to examine more carefully the role of gender in crisis-related transformation" (p. 89).

1 In this article, we use the terms thriving and growth as rough synonyms to signify posttraumatic changes that involve changes for the better attributed to the struggle with a highly stressful event. We also use the terms highly stressful event, crisis, and trauma as rough synonyms to indicate sets of circumstances that seriously challenge and may overwhelm the individual's coping abilities. See Tedeschi, Park, and Calhoun (1998) for a discussion of terminology in the general area of posttraumatic growth.

References Affleck, G., & Tennen, H. (1991). The effect of newborn intensive care on parents' psychological well-being. Children's Health Care, 20, 6-14.

Baltes, P. B., Staudinger, U. M., Maercker, A., & Smith, J. (1995). People nominated as wise: A comparative study of wisdom related to knowledge.

Psychology and Aging, 10, 155-166.

Bloom, S. (1998). By the crowd they have been broken, by the crowd they shall be healed: The social transformation of trauma. In R. G. Tedeschi, C. L. Park, & L. G. Calhoun (Eds.), Posttraumatic growth: Theory and research on change in the aftermath of crisis (pp. 179-213). Mahwah, NJ: Lawrence Erlbaum.

Bradburn, N. A. (1969). The structure of psychological well-being. Chicago: Aldine Curbow, B., Somerfield, R., Baker, F., Wingard, J. R., & Legro, M. W. (1993).

Personal changes, dispositional optimism, and psychological adjustment to bone marrow transplantation. Journal of Behavioral Medicine, 16, 423-443.

Freedy, J. R., & Hobfoll, S. E. (Eds.). (1995). Traumatic stress: From theory to practice. New York: Plenum Press.

Goodhart, D. E. (1985). Some psychological effects associated with positive and negative thinking about stressful event outcome: Was Pollyanna right? Journal of Personality and Social Psychology, 48, 14-148.

Green, B. L. (1994). Psychosocial research in traumatic stress: An update. Journal of Traumatic Stress, 7, 341-362.

Greenberg, M. (1995). Cognitive processing of traumas: The role of intrusive thoughts and reappraisals. Journal of Applied Social Psychology, 25, 1262-1296.

Greenberg, M., & Broadbooks, D. Y. (1998, August). Do social support and cognitive appraisals predict adjustment to HIV? Paper presented at the annual meeting of the American Psychological Association, San Francisco, CA. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.

Janoff-Bulman, R. (1992). Shattered assumptions. New York: Free Press.

Joseph, S., Williams, R., & Yule, W. (1993). Changes in outlook following disaster: The preliminary development of a measure to assess positive and negative responses. Journal of Traumatic Stress, 6, 271-279.

Lehman, D. R., Davis, C. G., Delongis, A., Wortman, C. B., Bluck, S., Mandel, D., & Ellard, J. H. (1993). Positive and negative life changes following bereavement and their relations to adjustment. Journal of Social and Clinical Psychology, 12, 90112.